Anesthesia Coding Alert

Question: A patient had an EGD with biopsy for dysphagia and a screening colonoscopy that included a biopsy. Would we report 00813-PT for the anesthesiologist?

Maryland Subscriber

Answer: Anesthesia code 00813 (Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum) is only appropriate in conjunction with 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) for a screening colonoscopy.

If it becomes a diagnostic/therapeutic procedure, include modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) and secondary codes for the established definitive diagnosis.

List Z12.11 (Encounter for screening for malignant neoplasm of colon) first followed by the finding that necessitated the procedure (i.e., colon polyp), the diagnosis for the EGD, and a co-morbidity if one is provided. The co-morbidity will justify the use of anesthesia.

Extra tip: Anesthesia coders do not typically assign as many diagnosis codes as the surgeon will report. If you’re reporting multiple diagnosis codes such as these (including COPD), it should be to justify the use of a higher-level physical status code.